I’ve been living in the Cheltenham area for several years now, and my family has used Abington Memorial Hospital’s services as needed. I’ve known the ob/gyn chair, Dr. Joel Polin, for many years professionally, and also know that he is as supportive of abortion access as I am. Not many abortions take place annually at Abington; somewhere between 50-100/year overall. But if many are like the procedures I once performed at an inner-city hospital in Philadelphia, these are not cases that could be done at a freestanding clinic such as Planned Parenthood or Philadelphia Women’s Center. Access to abortion within teaching hospitals is important, both for the patients and for the next generation of abortion providers (ie, the residents). Hospitals are much less of a target for anti-choice protesters, and it is also easier to manage the occasional complication (abortion is a very safe procedure, but complications minor and major can happen). A few years ago, I counter-protested against some anti-choice folks at Abington, and I know that the hospital had stood up for reproductive rights and maintained their abortion services in the face of some opposition.

That may change. In a very surprising move, the Board of Directors of Abington Memorial Hospital has moved forward with a Letter of Intent to merge with the local Holy Redeemer Hospital, a Catholic hospital located not far away in the Meadowbrook section. As a result, even though Abington is the stronger party financially, abortions, selective reductions and physician-assisted suicide cannot be performed at Abington under the merger.

Now, physician-assisted suicide is not permitted in the Commonwealth of PA, so that is a nonissue. But abortion and selective reduction will be forbidden at Abington, as they would be at any Catholic sectarian entity. Under agreement, contraceptive and sterilization access will be maintained at Abington.

Some might say that this is really not too bad. Unlike what happens at Catholic institutions, women will still be able to get their contraceptives, and men and women can also undergo sterilization. There will still be IVF services and other assisted reproduction at Abington (just as Holy Redeemer has reproductive endocrinology services that involve assisted reproduction). Not many women locally undergo abortion, selective reduction is probably very uncommon even with all the IVF and ovulation induction going on, and this isn’t Mississippi. There are abortion providers in the Philadelphia area, including a hospital-based service at nearby Albert Einstein Medical Center (disclaimer: I have an adjunct faculty appointment at Einstein, but have no financial or other interest in that institution).

But this is not a minor issue; this is a problem of nuclear proportions. And it’s not just about abortion, but affects women who have very desired pregnancies. Here are some questions and issues that help demonstrate why this is a big deal:

• Selective reduction (which is not always thought of in the same context as abortion, as the intent is to sacrifice one or more multiple fetuses to save the remaining); for those women with triplets, quadruplets and higher-order multiple pregnancies, they will either have to undergo reduction in Philadelphia or else take their chances with the outcome

• Preterm premature rupture of membranes (PPROM); will Abington physicians be permitted to induce labor in that situation or would they have to wait for intrauterine infection to evolve into sepsis? This is not a theoretical situation; this exact scenario played out with our former Senator’s wife (Karen Santorum). In that case, she made her own personal choice to delay labor induction. While it is not what I would recommend, I respect her choice as a patient. But that was her own choice, not one imposed upon her by a Catholic hospital.

• If there is nonreassuring fetal monitoring at < 26 weeks’ gestation, will women be given a choice of labor induction vs. stat classical Cesarean section (mandating future C/S)?

• Management of second-trimester inevitable miscarriage (eg, 18-22 weeks); will physicians be required to take unusual and medically futile measures?

• Provision of emergency contraception (EC); regardless of what the current plan and/or potential contract agreement is between the two hospitals, EC is (wrongly) considered to be an abortifacient by the Church and proscribed as much as surgical or medical abortion. So, if a victim of a sexual assault presents at Abington’s Emergency Ward (EW), will she be offered EC? At a significant number of sectarian and nonsectarian hospitals throughout Pennsylvania, EC is not offered to victims of sexual assault, so this is not a theoretical construct.

• Management of anencephalic and other lethal malformations detected with sonography or with other prenatal testing prior to, or past, the 24-week viability standard; based on Catholic teachings, abortion would not be available even in the presence of lethal anomalies

• Perinatal testing for pregnancies that are likely nonviable or severely compromised, with the potential for futile C/S if nonreassuring testing results from these actions

• Management of pregnant women with treatable cancers that are generally managed with pregnancy termination followed by definitive treatment of the malignancy (eg, stage IB cervical carcinoma diagnosed at 14 weeks’ gestation; one potential management option would be radiotherapy or D&E to terminate the pregnancy followed by gravid radical hysterectomy)

• What about the CREOG/RRC requirements to maintain AMH ‘s residency accreditation in light of the lack of training in abortion technique and aftercare?

• Will the merger affect standard management of ectopic pregnancies? I suspect not, but while treating a patient with a tubal pregnancy via laparoscopy at Graduate Hospital in the 90’s, a scrub nurse told me that if it were her, she would wait for her tube to rupture before taking action, since I was essentially terminating a life. This was a very good scrub nurse, and she knew very well the implications of untreated ectopic pregnancy, such as hemorrhage and death.

• How iron-clad is the commitment/agreement to continue to provide standard contraception and sterilization services?

• How will they weigh the life of a mother vs her unborn baby in circumstances where they may only save one life and the mother is not capable of expressing her desire? And would that differ from cases where the mother can express her desire?

• Management of severe non-immune hydrops fetalis during labor and deliver (ie, given the lethal nature of the condition for the fetus, will drainage of excess fetal fluid from various cavities be considered to effect vaginal delivery, or would that be proscribed as being similar to intact D&E?)

These are just some of the things I came up with off the top of my head in a few minutes the other week. I’m sure there are others I did not think of.

Abington Memorial is one of the largest hospitals in the county. While it is not a major academic medical center like Mass General or the Hospital of the University of Pennsylvania, it is a very large hospital that does more deliveries per year than many hospitals in the area. Over the past several years, we have lost many obstetrical services in the Philadelphia area; the hospital where my daughter was born is now a hospice or some other outpatient facility (ironically, owned by Abington Health). Two local hospitals within a short distance of Abington Memorial, Jeanes and Elkins Park Hospitals, no longer have OB care. It is not feasible for most women in the Abington/Jenkintown/Cheltenham area where I live to travel into Philly for their OB care and delivery, nor will most people choose to go to Einstein; it’s a good hospital, but it’s in an underserved area and most folks in my area just don’t go there. Einstein is building a new facility in the Blue Bell area, but unless you’re really determined to avoid Abington at all cost, it’s quite a hike from this area. So for all practical purposes, most women do not have other good options for their OB and other care.

I have nothing against Holy Redeemer Hospital per sé. It is a good hospital. My children see pediatricians in their medical office building. I have to remind myself that it is a Catholic institution; unlike places like Mercy-Suburban and other hospitals that are affiliated with the Sisters of Mercy, Holy Redeemer doesn’t wear its Catholicism on its sleeve. I’ve yet to see a cross there, not that there is anything wrong with it (the Pieta of Michelangelo is one of my favorite sculptures, ever). But my point is that it has a pretty low-key approach to being a Catholic hospital, to its credit. But at the same time, it remains a Catholic hospital. And while the folks who run it might be willing to look the other way when Abington, under the merger, provides sterilization and contraceptive care, they clearly will not, and cannot, support any affiliated entity having anything to do with abortion. Low-key, yes, but there are limits.

So that’s the quandary. In order to have this merger go through (and the business rationale for the merger, other than the value of the land Holy Redeemer sits on for additional office and OR space, escapes me), Abington will have to adhere to the directives of the Catholic Church as regards abortion and selective reduction. I respect all religions, regardless of my own atheism, and while I might not agree with Holy Redeemer banning abortion within its own hospital grounds, it is well within its right to do so. The problem is when sectarian hospitals merge with nonsectarian ones and impose their own sectarian beliefs on medical care delivered at the formerly nonsectarian institution.

We live in a diverse country, which is a good thing. And the Cheltenham/Abington/Jenkintown PA area is known for its diversity and generally progressive population of all religions, ethnicities and backgrounds. So the idea that a proposed takeover of a Catholic hospital would lead to the loss of abortion services at our most prominent local hospital, the one that is the stronger institution at this time, is mind-boggling and offensive to many in this area. As a result, more and more people are taking a stand against the merger, and that’s a good thing.

I’ve sent e-mails and received canned responses, so I imagine most people who write will receive similar responses from the Abington management. But the more people write, the more the board and other management at the health system know there is solid opposition to this.

We also need more physicians on staff at Abington to speak up and, if it comes to it, even resign their positions. When I was an attending physician at one Philadelphia hospital, I ended up leaving to go to Pennsylvania Hospital in large part because my former dept. chair was anti-choice and decided to go over my head and cancel one of two second-trimester abortions I had scheduled in the OR there (he couldn’t cancel the second patient, much as he wanted to, as I had already placed laminaria into the cervix to prepare it). At some point, we physicians need to uphold our own principles and ethical standards. If we cannot make a decision based on medical evidence but have to comply with religious dogma in certain situations, all of us have a choice to make in terms of whether or not that is acceptable based on our interest in providing the best medical care for our patients.

Abortion is not a happy procedure, unlike much of obstetrics (although OB is often anything but happy, but that’s another discussion). I’ve never had a patient who took it particularly lightly, or who loved undergoing the procedure. But it is often a necessary procedure, both medically and from a public health standpoint. Some of my colleagues have died for providing this legal procedure. LeRoy Carhart, whom I’ve spoken with and admire greatly, has had his life disrupted and threatened on multiple occasions for his dedication to providing this service to his patients. Warren Hearn, whom I also think very highly of as a physician, is often under armed guard due to threats against his life. Those of us who have provided abortion services do not have an easy time of it. Besides the protestors and the inappropriate social stigma, many of our own colleagues (even in ob/gyn) disrespect us and treat us like undesirables. So when I hear of yet another hospital that will no longer provide abortion services, it touches a raw nerve. Many people have worked for years to do whatever they could to make sure that women at least have some places where they can exercise control over their own reproductive destinies. That’s because a lot of us feel that women who cannot control their reproduction are not truly free. So this is important to those of us in women’s healthcare, and from the responses to the Abington Board’s decision, I’m glad that this is very important to a lot of people in the local area as well.

Feel free to e-mail the management of Abington Memorial Hospital. Just to make it easier, here are their e-mail addresses (keep it civil and polite, however. This isn’t personal):

Thank you so much for writing this very logical, medically informative and straight-forward piece. I am currently 16 weeks pregnant (happy to be!) and I find myself disturbed by the events transpiring at AMH. Luckily my OBG care is at another hospital that is unaffiliated due to my location, but other women are not so fortunate. Were I to find myself in the horrific situation of medically requiring an emergency termination of my pregnancy- I can’t imagine having that choice taken out of my hands or being delayed life-saving treatment to transfer to a distant location. I do not want my medical treatment in the hands of religious crusaders- I want it in my hands and the hands of my doctor. The impact of this merger is far-reaching and deeply concerning. It is because of voices such as yours that women have come as far with our medical care as we have. It is an ongoing pursuit and without the aid of doctors willing to stand up for what is medically, morally and humanely right- we would have been silenced often in history and drowned out by politics presently. Reading posts like these reassures me that there are doctors that are willing to do the right thing, sadly at times to their own detriment. Doctors should not live in fear of their lives, their well-being, their reputations amongst colleagues for doing what is best for their patients in their medical view. I can’t imagine being ostracized for standing up for basic human rights and liberties. I imagine many doctors at AMH, as well as locally, are facing personal and professional repercussions due to this merger or their opinions. Thank you for having the courage to speak out and for being a voice of reason within the local and medical community.

I’ve been skeptical of the Susan G. Komen Foundation (or as they call themselves, “Susan G. Komen For The Cure”) for a long time. And then I learned that much of their funding simply doesn’t go towards breast carcinoma research. And then I learned that they sued several nonprofits all because they used the term “cure” in their marketing. It all seemed like a scam to be on a massive scale, but then I talked myself down a bit, since any efforts towards even education and screening for breast cancer can’t hurt. I do think other cancers are woefully underfunded, such as ovarian cancer (which also kills many women) and pancreatic cancer (again, I’ve known too many women who have died from the disease). But that doesn’t mean that breast cancer shouldn’t be funded. So I didn’t make waves and did the Race for the Cure in Philadelphia every Mother’s Day.

But now, I say Boycott Komen.

Yesterday, it was announced that Komen is defunding breast cancer screening efforts at Planned Parenthood centers nationwide. That amounts to between $700,000 and $800,000 annually. I used to be interim medical director at Planned Parenthood in Philadelphia, and also provided abortion and well-woman care at several Planned Parenthood centers in the Philly area. Most of the women I screened for breast cancer were not of means, and PP was essentially their only health care provider. So what Komen just did was hurt these and other women who rely on such services for their general medical care, including annual breast cancer screening.

Komen claims it did not act out of political pressure or pressure from the antichoice crowd. Rather, they claim it now has a policy of not funding organizations that are under federal investigation. Yes, PP is under investigation for misappropriation of federal funds towards their abortion services, which has never been demonstrated to be true and there doesn’t appear to be evidence of this now. But some jackass in the Congress decided to go after PP because of their provision of abortion services. So without any evidence or proof of “guilt,” Komen just caved in and pulled all their funding. And then there’s the fact that their new VP, former GA governor candidate Karen Handel, was well known to be a pro-lifer who was very much against Planned Parenthood. But I’m sure that is just a coincidence.

This is such a bad decision that it absolutely defies rational explanation. It is total idiocy. This should have nothing to do with abortion. But at the same time, it should be said that abortion is overregulated, unjustly tarnished and very much represents an important public health need. Childbirth is 14x more hazardous than abortion. Yet, no one is promoting legislation to warn women against carrying their pregnancies to term. Somehow though, it’s considered ok to pass burdensome and ridiculous laws requiring women to undergo sonography to look at their fetuses and to wait at least 24 hours before being able to have an abortion after providing informed consent. As if any woman wakes up and says “What the hell, I’ll go have myself an abortion today.”

Women of all backgrounds should be pissed by what Komen did today. Men of all backgrounds should be just as pissed.

So I will do some research and update this post with ethical nonprofits related to breast cancer research that are far more worthy of our donations than Komen ever was.

But if nothing else, Boycott Komen.

UPDATE 2/5/12
At the end of this article, there is a nice list of groups that spend nearly all of their funding on research and treatment.

Yes, boycott Susan G. Komen Foundation for their de-funding of Planned Parenthood. Placing polical ideology over thier supposed aims and goals (preventing and/or curing breast cancer) by making breast exams for women LESS available is helping whom in this fight?

I agree; boycott Susan G. Komen Foundation. I will never support another walker or this organization. My funds will go directly to Planned Parenthood and other organizations that truly support women’s health. it is disgusting that Susan G. Komen pulled funding and then tried to lie about it.

I just sent a letter to the editor of Medical Marketing & Media (no idea why I get it, let alone read it), complaining about a column written by a NYU internist in favor of restricting emergency contraception to “by prescription only.” He feels if it were available to teens over the counter, it would be “a mistake.” The FDA disagrees with him, as do I. Sadly, the Obama Administration overruled the FDA.

To the Editor:

While I have always considered Dr. Marc Segal’s column in Medical Marketing & Media to typically represent views that are conservative and thus quite the opposite of mine, I was particularly taken by his remarks against making emergency contraception (specifically, Plan B) available over the counter to young women under the age of 17. In contrast to the findings of the FDA committee that recommended its approval, Dr. Segal puts forth several rationales for his decision that fly in the face of medical evidence.

For example, he maintains that OTC status would pose a risk of ectopic pregnancy, as he postulates that young women might assume Plan B has worked and fail to heed signs of an ectopic. There is no data to support this, and even if Plan B were not available, women of all ages may have an undiagnosed ectopic pregnancy regardless of the availability of emergency contraception. Taking EC does not make one more likely to “ignore” signs of an ectopic pregnancy.

I suspect his issue is more with the primitive, and unproven, notion among some people that anything that prevents undesired pregnancy will somehow corrupt our youth. This is suggested by his assertion that making Plan B available without prescription to teens would lead to “Undiagnosed sexually transmitted diseases that often accompany unprotected sex in teens.” I realize that Dr. Segal is not a gynecologist, but even he should know that STDs may accompany unprotected sex regardless of whether or not emergency contraception is available. The availability of emergency contraception does not increase licentiousness or STDs. It does, however, decrease the incidence of undesired pregnancy, and also can decrease the need for abortion. Indeed, one of the sad things is that despite the availability of Plan B to adults, many do not take advantage of it.

I do not disagree with Dr. Segal’s assertion that “A discussion about sex and pregnancy is an opportunity for a discussion between a doctor and a teen…” But in reality, such discussions often do not take place in medical offices. Nor do many teens (and adults, for that matter) heed a physician’s advice about sexual intercourse, smoking, or many other lifestyle matters.

All drugs have side effects. That includes all medications that are available over the counter. The known side effects cited by Dr. Segal, such as “Allergy and facial swelling” and “Nausea and vomiting” are also side effects common to many OTC drugs. Aspirin can be nephrotoxic and induce gastric bleeding and platelet dysfunction; acetaminophen is well known to be hepatotoxic at higher doses. Does Dr. Segal suggest those drugs be restricted to “by prescription only?”

Teen pregnancy is difficult and generally undesirable. We need to do more to prevent it. Emergency contraception is one approach, and I’m disappointed that any physician would propose in a national magazine that EC not be made available to teens under OTC status. Again, the FDA had recommended Plan B be made available over the counter, and regrettably the Obama Administration, probably for political reasons, chose to ignore their evidence-based recommendation. Unproven speculation about treatments with an important benefit for public health should not be given credence by publication in a magazine such as yours.

I’m in the EU this week (was in Birmingham, UK earlier this week and am now in Utrecht, The Netherlands) for work, meeting with various gynecologists, and I heard something today that made me stop what I was doing and say “Wow.”

Each week, all the gynecologists at the local hospital here get together to meet and discuss each of their forthcoming surgical cases. They are asked why they are doing them, what alternatives might be considered, whether the patient is appropriate for the procedure, whether such treatment is consistent with standard evidence-based guidelines, etc. I commended my colleague and said this was a great idea. Then he indicated surprise that I’d be at all surprised by this; apparently it is not only standard of care here in The Netherlands, but also is done in the UK and elsewhere. But not generally in the US. Other than occasional multidisciplinary groups, like the treatment planning groups at MD Anderson Cancer Center in Houston in which a radiation oncologist, gynecologic oncologist and medical oncologist all meet and examine the patient and then discuss what the appropriate initial treatment should be, I don’t know of many instances where physicians in the US get together to prospectively plan treatment. But what they do in the EU goes beyond this-it is not limited to complex gyn oncology patients (where a multidisciplinary approach really is critical, and something that I wish were performed more widely rather than just in large cancer centers), but is essentially a peer-review process in which one’s colleagues get to discuss whether or not what you’re planning to do makes sense.

Why is this such a nice idea? Because in the US, any of us can pretty much do whatever the hell we want to with our patients, evidence-based or not. If we decide Betty Yifnif should have a hysterectomy for fibroids, then that’s what is offered. If we decide she should have more conservative treatment, then great. If we decide to do an abdominal hysterectomy rather than a less morbid vaginal hysterectomy, that’s ok too.

In other words, there is little or no proactive oversight of what any of us surgical types do, outside of some preauthorization by third-party payors. In the UK, the National Health Services (NHS) has strict guidelines that one should perform vaginal hysterectomy rather than laparoscopic hysterectomy due to the known increased complication rate from the latter. Unlike the US, the NHS has reduced its benign hysterectomy rate by mandating that less invasive, more conservative therapies are offered first. Therapies such as the levonorgestrel intrauterine system (LNG-IUS; Mirena) or nonresectoscopic endometrial ablation (NREA).

What happens in the US? We also have NREA. We perform 450,000 of these procedures each year. Yet we’re still performing the same 600,000-650,000 hysterectomies each year for benign uterine conditions. Which begs the questions that I know the payors are also asking: why are we doing so many NREA procedures if they’re not coming out of the women who are otherwise appropriate for hysterectomy? Perhaps it might be because NREA is a pretty easy, blind procedure that is fairly quick and also very well reimbursed?

I know that there is a lot of bitching and moaning by many of my colleagues in the US about evidence-based guidelines and how health care reform will require too much “cookbook medicine” by physicians. Just mention “pay for performance” and observe the look of frank hatred on most physicians’ faces. Look, I hate being told how to practice medicine as much as the next person. But at the same time, there should be some agreement that certain things really need to be done in the majority of patients with a certain condition or disease. Can’t we agree that if we have a diabetic, he/she should have a hemoglobin A1C determination several times per year? Is that unreasonable?

And if someone has fibroids, why not require that the physician consider other options rather than simply whack out the uterus? There certainly are women who desire hysterectomy regardless of other options being available. I’ve had patients who listened to me present several options that were less invasive, and they chose hysterectomy. Those cases I can’t argue with-it’s the woman’s choice, whether I agree with her decision or not. But in many cases, it isn’t the woman’s choice. It’s the physician’s choice. And therein lies the problem.

If someone were to ask me if hysterectomy is required for some women with fibroids, I’d probably answer no, that myomectomy (removal of the fibroids with preservation of the uterus) is almost always technically feasible. I used to remove 40-50 fibroids in some women, and never had to then do a hysterectomy or transfuse blood. I’m not saying that it isn’t possible that after removing that many fibroids, there may be too little normal uterus to surgically restore to normal anatomy. But it never happened in my experience. So at least in the vast majority of cases, myomectomy is absolutely possible. Not every gynecologist may be particularly comfortable doing multiple myomectomy, and while I find that strange, given that this is a standard operation that is taught in residency, that certainly seems to be the reality. So why not refer the patient, then, to someone who is comfortable doing uterine-preserving therapy?

Back in the late 60’s, one of the main ob/gyn journals had a paper that argued the following (and no, I’m not making this up):

“The uterus has but one function-reproduction. After the last planned pregnancy, the uterus becomes a useless, bleeding, symptom-producing, potentially cancer-bearing organ and therefore should be removed.”
Wright, Obstet Gynecol 33:560, 1969.

In the same vein, the edition of the surgical gynecology text from my residency and fellowship years said the following about myomectomy:

“Although it is unusual for myomectomy to be technically implausible, the procedure may be difficult, time-consuming, and associated with a substantial complication rate…Hysterectomy usually is a simpler procedure than multiple myomectomy, as well as the procedure to which most gynecologists are more accustomed.”

Te Linde, Operative Gynecology, Seventh Edition

So what if we had surgeons and gynecologists meet with their colleagues and critically review each case they are planning to do, in order to see if it really passes muster with the general consensus and expert opinion? I suspect it couldn’t happen in my country, since we all love our autonomy and hate the increasing encroachment upon our clinical judgment. I empathize, but only to a degree. All I have to do is then think about the fact that hysterectomy rates vary widely from one part of the country to another, and the fact that at Brigham and Women’s Hospital, I was encouraged to do many operative deliveries with forceps but no one was allowed to do vaginal breech deliveries while across the street at Beth Israel, their residents could do neither, and in Philadelphia, I could do both. That says, right there, that this all has little to do with evidence and much to do with individual judgment or lack thereof.

I think you need to research this a little more.
We meet EVERY morning as a group, attendings, fellows, PAs and nurses and discuss EVERY procedure we are planning to do. It is not uncommon after the discussion to change the plan. We also discuss every patient on our service and our consult service. This is not unique, I know many other programs that do the same in the US. Your comment “we can do what ever the hell we want..” suggests you do not actually practice medicine. This could not be farther from the truth. Perhaps we can do what we want, but we won’t get paid and the jJustice Department just might come knocking

I disagree. I can see from your e-mail address that you are either at BWH or The General. I was a resident at both institutions. When I was on the private (Baker) surgical service as an intern, they started having M&M conferences. The surgeons were extremely uncomfortable with the idea. That was a ways back, but just the thought of reviewing morbidity and mortality instilled quite some angst. I don’t doubt that some groups at MGH and probably some other major academic institutions do prospectively review cases. If you reread my post, I noted that this was not “generally” done on this side of the pond, and I stand by that. And yes, many physicians do feel that they have the autonomy to prospectively do whatever they want. They might not get reimbursed, but they still can proceed and do unindicated hysterectomies, endometrial ablations and other procedures. Do you not dispute that there is something very wrong that hysterectomy rates vary so widely without any clear evidence that hysterectomy is better than conservative therapy for many benign uterine conditions?

I am not sure if this will be published or not, but it was sent to the Philadelphia Inquirer this morning:

To the Editor:

I am a gynecologist, formerly in practice in Philadelphia, who provided abortion care for many years to my private patients as well as to those at three area women’s health centers. I am appalled but not surprised by the events surrounding the clinic run by Dr. Gosnell; it was an open secret among abortion providers that his practice was subpar and not reflective of the generally excellent care most abortion providers give to their patients. I had performed abortions in women who had come to his clinic for an abortion, sensed that something was not right, and fortunately left before receiving care at that facility. What surprised all of us is the fact that no local or state authority acted on longstanding concerns about the “clinic” in West Philadelphia. And while the National Abortion Federation’s guidelines and inspection process currently lack teeth as they are not a state or local health body, I think it does have an obligation to provide better oversight of member clinics and individual physicians. Unfortunately, only a portion of abortion providers are members of NAF, and like Dr. Gosnell, would not be subject to any enhanced regulation by that organization.

I do believe that outpatient abortion clinics should be evaluated in the same light as any other outpatient facility, but also not targeted or treated more onerously than a cosmetic surgery or outpatient surgical facility.

But lost in all of the media reports about the “house of horrors” in West Philly, is the fact that women came there because they often did not feel they had access to a safe, legal abortion. Abortion care is not generally reimbursable under medical assistance plans thanks to the Hyde Amendment. And thanks to terrorist groups like Operation Rescue and the assassinations they have inspired, many of my colleagues simply will not provide abortion, making subpar and dangerous physicians even more likely to make up for the decreased supply of qualified abortion providers. If anyone wants a preview of a future without Roe vs. Wade, look to that “clinic” in West Philly.

Most abortion providers and clinics provide excellent care to their patients. Indeed, abortion is one of the safest surgical and medical procedures out there. However, society and, in particular, many hospitals and medical schools have marginalized abortion. That marginalization will only make it more likely that unqualified people will provide abortions to women who lack the means to obtain safe and legal abortions. It’s time to stop this marginalization, and also elevate abortion practice to the quality standards and payor reimbursement it deserves, on a par with every other routine, standard and common gynecologic surgery procedure.

I’ve been involved in social networking for many years, even before it became fashionable. In particular, I was interested in social networking for physicians-there are many potentials for good when doctors communicate amongst themselves, and all of us learn from one another. But most physician social networks come up short-they try to do too much, or else try to be another MySpace or Facebook clone.

A few years ago, Sermo came out with a big bang and a lot of promise. It was a site that was all about conversations among physicians. It wasn’t filled with the usual “talking heads,” but physicians from all walks, who could provide unfettered clinical advice to one another. Drug companies and the AMA signed up early on, since being able to observe (but not join in ) conversations among doctors is a gold mine to them. One thing the AMA learned was that most of us detest the AMA, and eventually there was a major falling out between Sermo and the AMA, reportedly after physicians on Sermo finally woke up and realized the AMA owns the ICD-9 codes that determine physician payment for procedures.

Anyway, I became disenchanted with Sermo soon after that. Not because of the AMA thing, but because I was finding so many of my colleagues on Sermo were conservative. Extremely conservative. And very angry. They were the forerunners of today’s Tea Party crowd, and in retrospect, it was like having multiple conversations/debates with Rand Paul and his ilk. I was labeled a “communist” for having the audacity to even mention the term “universal health care.” I was compared with Noam Chomsky in ways that did a disservice to Chomsky and me simultaneously. The only respectful conversation with a conservative on Sermo, I think, was with a female psychiatrist who trolled all the ob/gyn posts in order to promote her pro-life agenda and rail against godless abortionists like myself. At least she never resorted to personal attacks (nor did I) and it was all civil. That was the best of it in terms of dealing with conservatives on Sermo. There were some progressives, and some of them occasionally chimed in. But it was usually me against several conservatives and I was often dying for some reinforcements who never came.

So I stopped participating in Sermo. At one point, I was #4 among all gynecologists on the site in terms of participation (note-at the time, there were only a few hundred ob/gyns on Sermo, another reason I wasn’t that thrilled with the site-it is still mostly made up of family physicians and internists who talk about things that bore surgical types like me to death). Over time, I went on perhaps 2-3 times a year just to convince myself it was still a waste of time. While it was good that this wasn’t the usual physician site where experts lectured others from Mt. Olympus, it would have been nice to have some folks with significant credibility, since many responses seem to have been authored by the same frequent flyers on the site, none of whom necessarily had any specific expertise in the topic at hand, nor did they provide true evidence-based advice. Anecdotes ruled the day, and while clinical experience and anecdote can be helpful, they’re not definitive.

Recently they updated the site, which was good in terms of Web design. I went back a few days ago to check it out and liked what I saw in terms of UX and functionality. But if anything, it’s even more rabidly conservative now in terms of the physicians who participate. There’s a big post on Atlas Shrugged by Ayn Rand. “Obamacare” is routinely derided, with fear tactics about how physicians will be put out of business (?physician “death panels” perhaps?), how Medicare is being gutted, etc. Even better-a pathologist suggested there would be “armed rebellion” against the government because of its policies, and all this was a consequence of Obama being Kenyan. Great-a pathologist birther. Usually my colleagues in path are very smart and focus on factual evidence. But I guess on Sermo the kooky pathology types come out with conspiracy theories. A ludicrous article by the conservative Heritage Foundation is used by physicians on Sermo to support their hysteria about the evils of health care reform. That’s what it’s come to on Sermo-using a conservative think tank to support your position on a major health care issue. These folks, based on their posts, hate health care reform, hate the government, think our President is a communist, etc. Do they have issues with government intruding on the rights of women to have an abortion? Apparently not. But if the government is even incorrectly perceived as interfering with a physician’s reimbursement, then they want “armed rebellion.”

In other words, many of the physicians on Sermo represent the worst stereotypes people have of doctors. These are angry, irrational types who seem to just be miserable about everything and believe whatever Faux News tells them.

Now, I’ve known since med school that most doctors are conservative. Hell, my best friend from med school supports Bush to this day, and I still am good friends with him. It’s okay for people to have different opinions. If everyone agreed, life would be terribly boring. But there’s a difference between having a different opinion and calling someone names. Physicians are also supposed to know the difference between objectivity and opinion. There are many good resources on health care reform that are unbiased and nonpartisan. And I have issues with the current health care reform legislation, mostly because it seems to me to be confusing, woefully suboptimal and didn’t go far enough to ensure health care for all and also protect a woman’s right to choose abortion. I wanted a single payor system, in all honesty. That puts me at odds with the great majority of physicians on Sermo, and that’s okay. But the great majority on Sermo seem to be enchanted with the Tea Party philosophy of ranting without constructive solutions. And this is disturbing to me.

Certainly the majority of posts on Sermo relate to clinical matters and the discussion can be helpful, and at least not snarky. But too often, even on clinical threads, the conversation degenerates into editorializing and even all out warfare.

In daily life, I interact with many physicians, most, if not all, of whom are not like what I see on Sermo. But I think Sermo, like any other Web-based social network, is prone to snarkiness because of the semi-anonymous nature of the Web. Most of the physicians do not have any identifying information, so the most quiet, benign physician could rant all he/she wants on Sermo without any repercussions since no one has any idea of his or her identity in most cases.

We need good social networks for physicians. I appreciate the AAGL listserv, where all of us gyn laparoscopy folks communicate on clinical matters. But it’s moderated, and we’re all in the same specialty and most of us know one another so it tends to be a supportive crowd, even with a diversity of opinions on clinical topics. Sermo desperately needs some moderation. Normally, I hate moderated forums-it goes against my “socialist” grain, I guess. In many cases, I like the unbridled free-for-all that is the Web. But too many times on Sermo and some other forums (new music ones in particular), the conversations turn ugly fast. Someone needs to be the grownup. There are too many ranting two-year-olds on Sermo who would benefit from a “perfect nanny.”

I don’t agree with your conclusion, at all. Censorship of any kind among consenting adults is always deleterious. (If you are wondering politically I stand I am a centrists on workdays and I am a moderate leftist libertarian on weekends)

I am not a fan of censorship either. Far from it. But when you get called things like “socialist, ACLU-loving, boorish, self-important jackass” by presumably intelligent and grounded colleagues, I think it’s time for some adults to step up to the plate, no?

Nah, just ignore those comments or let them have it: you chose, just like anyone else, that is what is great about it, you get people real opinions, the ones you would never hear offline even though they exist. You can also sort out very quickly who is worth reading and who is not. I am all in favor for pseudo-anonymity so long as the screen names remain stable.

Oh, I let them have it, and that brought a deluge. I wouldn’t have minded, except that duking it out online with 10-20 angry conservative physicians without some reinforcements on one’s own side is ultimately draining, and a waste of time. I stand by what I wrote. I think it’s one thing to debate, another thing to call people names. That’s childish and I expect more from other physicians. The liberal bashing has always been there on Sermo since many of the doctors clearly hate health care reform, hate Democrats, etc. Happy to join them in complaining about malpractice lawyers-I know we could find a lot of common ground there. But I’m not a punching bag.

As far as anonymity-it’s a double edged sword. Personally, I think that if you have the courage of your convictions, why be anonymous? I really think it’s much more likely for people to get nasty and offensive when they’re anonymous. You do get their real opinions, and perhaps that’s a great thing regarding clinical matters. However, I’ve never had to hide behind a pseudonym when discussing clinical issues on the Web with either doctors or patients. If these folks really believe that liberals are socialists who all want to jam totalitarianism, crappy Medicare reimbursement rates and “restrictive” health care reform down physicians’ throats, then they should have the cajones to not hide behind a pseudonym and actually identify themselves. Just sayin.

Very well written post. It simply proves that the level of education and intelligence doesn’t matter when it comes to people who become brainwashed by constant bombardment from sources like conservative radio and Fox News. The same people who, one would hope, use careful judgement based on proven facts in their medical practice simply adopt the techniques of the sources they get their information from. How does one win an argument on conservative radio or Fox News? By stating outright lies, shouting down and personally insulting their opponent. Is it any surprise that people who take these sources of information seriously adopt the same approach?

I worked at Sermo at one point and I can tell you that the company’s founders shared the opinions of most of the doctors on there and were actively involved in lobbying against Obamacare. Absolutely hated the current president.

Lots of good stuff going on, but I’ve been swamped so have not had time to blog.

Next Thursday, August 6th at 7:30 PM, Bill Solomon and Mike Lunoe will be premiering my work for six marimbas titled bs piece (double canon for bill solomon) at the Berkman Recital Hall, Hartt School of Music in W. Hartford, CT. I’m listening to their latest rehearsal tape right now and it’s absolutely incredible. How they manage to play this without getting lost while syncing with a tape of the other four marimba parts and counting accurately how many times to repeat each measure (17x is not uncommon in this piece) boggles my mind. Kudos to them both for not just taking on my music but for realizing it so perfectly. The score is here. I’ll be posting a MP3 of the performance and possibly even a video once I get it from Mike and Bill.

Just got an e-mail inviting me to be on the Editorial Advisory Board of the Journal of Minimally Invasive Gynecology, the official journal of the American Association of Gynecologic Laparoscopists. Obviously they’re extremely desperate.

Composer/performer/MIDI artist Steve Layton is going to be releasing his realization of textbook: music of solitary landscapes in hyperspace (piece for IPS) via iTunes in the coming weeks. Steve’s realization is excellent and took him at least two weeks to accomplish. The piece is over two hours and is continuous, although it will be broken into individual sections for downloading.

As one of the diminishing number of physicians who performed second trimester abortions, I can state unequivocally that it is never a procedure that is approached in a cavalier fashion. Not every gynecologist can perform it, even if trained appropriately. The sad thing is that we’ve done a really bad job at training the next generation of providers. I taught many residents, but of those, many will not provide abortion services for a variety of reasons. Part of why this is is that abortion has been marginalized. People don’t want to talk about it. My colleagues for the most part didn’t want to deal with it. Some couldn’t say the “a-word,” substituting euphemisms like VIP (voluntary interruption of pregnancy). Abortion is a very common procedure. It is a necessary procedure. But it will be an extinct, forgotten procedure if clinicians are not trained to do it safely and compassionately. We need to get it back into the hospitals so that it is again part of routine gyn practice. Abortion training must be made more widely available within residency training programs. It’s idiotic that many ob/gyn residency programs do not offer in-house abortion services, but must send “interested” residents to outside clinics, often on their own time during weekends.

When I was in practice, I did a lot of procedures in ob/gyn. Including abortion. Some of my most grateful patients were those for whom I performed an abortion. I never performed any abortion without being absolutely certain that the patient desired it and that it was her own decision. That’s what “choice” is about, after all. My abortion patients didn’t wake up that morning and decide “What the hell, I think I’ll have an abortion.” This was a very, very difficult decision for any woman to make. People who have not walked in their shoes should not be making judgments or regulations about this most private and personal of medical decisions.

All of us who either performed or continue to perform abortions need to finally stand up, be counted, and say “enough.” Abortion providers have this terrible stereotype of being slimy, scumbags in the margins of the medical profession. We’re not. A lot of us are academics. We’re honorable. Most of us have delivered babies. All of us provide or provided services that are challenging and that many physicians either can’t or simply won’t provide. Rather than honor abortion providers, society (including many physicians) treats them like criminals. This must change. While I recognize the potential danger in coming out as an abortion provider, there is strength in numbers. And just as the Gay community came out and took steps to remove the stigma of being gay, abortion providers should stand up, be proud, and demonstrate that we’re here to stay. Only when abortion is de-marginalized can we start addressing the onerous restrictions on the provision of abortion services and also combat the insidious demonizing of abortion providers. Such demonizing was absolutely behind the assassination of Dr. Tiller yesterday.

I’m currently in my last year of medical school. I have organized abortion training opportunities at my school since my first year. Now that I am in my internship years, I have also had the privilege of working with and learning from practicing providers. I am looking forward to a career where I can be involved in the full spectrum of women’s reproductive health. An abortion-providing baby-delivering doctor is not an oxymoron. In fact, I think it is a pretty awesome combination.

Your call for “coming out” of providers does not fall on deaf ears. I agree with you completely. I’m not quite there yet, unfortunately. The pseudo-anonymity of twitter et al. has made it easier for me to share my thoughts and passions. As I gain confidence, and, more importantly, a sense of interconnectedness to like-minded people, the need for anonymity is diminishing.

Thanks very much. I really appreciate your comments. And no, it is not at all an oxymoron. I did it as well, although I confess I was more of a laparoscopic surgeon than an obstetrician after awhile.

Don’t rush the “coming out” part. It’s an individual choice. I was very careful when I was in practice, especially after I had my daughter. It changes one’s perspective, since it isn’t just about you. But being careful isn’t synonymous with denial. I never lied about what I did and remain proud and humbled to have provided this service to many women. But it’s admittedly easier to be “out” in terms of abortion once one has left clinical practice. Many of my fellow abortion providers were genuinely scared in the 90’s and with good reason. Several providers were shot and killed, along with courageous volunteers and staff. That changed things quite a bit. So there’s nothing wrong at all with flying under the radar. But still, many established providers need to declare themselves or at least not deny what they do when asked. The more providers who speak out, the better. Good luck with your training. Guess I can’t talk you out of being a doctor. 8-)

I happened upon your blog in light of Dr. Tiller’s death, and I just wanted to express my utter gratitude for the work you do, and the courage and honesty with which you carry out your duties. I’m a Canadian woman, so things are a bit easier for us up here, and although I’ve never needed to consider an abortion I have friends and family members who have; and I am grateful that I live in a country that respects a woman’s life enough to allow her the courtesy of being the sole decision-maker in the choices that will most affect her.
I was born in 1980, so I grew up as a member of the first generation of Canadian women to go trough puberty post-Morgenthaler (the SC decision that abolished the last legal restrictions on abortion in Canada). Because of this, I’ve never had to go through the agony of having nowhere to turn, nor have any of my friends of similar age. I haven’t lost friends to butchers, I haven’t known anyone – of my age – to have their dreams of future children taken away from them as a result of complications from an illegal operation (although I have met older women who have had to live with this).

And for this freedom, this luxury of choice, I have you, and others like you – doctors, nurses, and other health care providers & supporters – to thank. To you and future doctors like the one who commented above me on this thread, THANK YOU, THANK YOU, THANK YOU. Although we are from different countries, with different laws, the stand you make strengthens us all.

I’m no longer in practice, incidentally, and regret not being able to provide this service and train residents. Our health care system is very different from Canada’s, and many gynecologists end up either changing states or leaving practice entirely. Hopefully Obama’s health care reform will take hold—we need a better system.

I just read that someone assassinated Dr. George Tiller, an abortion provider in Kansas who was one of the few people who were skilled at and willing to perform abortions above 20 weeks’ gestation. Dr. Tiller was shot while attending church services near his home.

For those of us who perform or performed surgical abortion, Dr. Tiller, along with Dr. Warren Hearn in Colorado, epitomized the highest ideals of medical service. Regardless of one’s stand on abortion, Dr. Tiller was a true professional who performed abortion above 20 weeks despite many obstacles, including onerous regulations, overzealous protestors, death threats, a bombing and the shooting of both of his arms. He didn’t perform abortion for monetary reward; in general, there are far less dangerous ways to earn significantly more revenue as a physician. Rather, Dr. Tiller did what he did because it was necessary, and because midtrimester abortion is best provided by someone who has the patient’s best interests at heart.

This also demonstrates how critical it is that residents and other physicians get appropriate training in abortion services. While I provided second trimester abortion services while in practice here in Pennsylvania, I never performed one above 20 weeks to the best of my recollection, and as a resident would go to 24 weeks, but only using saline and prostaglandin amnioinfusion above 18 weeks. Dr. Tiller provided safe, legal surgical abortion up to, I believe, 28 weeks, which requires a great deal of art and skill to pull off without complications. Now that he is gone, there are far fewer people out there with that skill and experience. Only Warren Hearn comes to my mind, although I’m sure there might be a few others.

Dr. Tiller’s murder is another indication that we need to come together and find common ground. No one is more pro-choice than I am, period. I’ve performed many abortions, introduced medical abortion to my hospital in the days before mifepristone was available, lectured about abortion technique and taught many residents how to provide a safe surgical abortion in a compassionate fashion. I’ve never dissembled about my role as an abortion provider, and am very proud of what I did. Indeed, my patients for whom I provided abortion care were often among my most grateful patients. I’ve marched on DC twice in support of abortion rights, actively supported pro-choice candidates and have always been willing to donate money to the cause of reproductive rights. That said, I’ve also worked to find areas of agreement and cooperation with reasonable people on the pro-life side of the divide. I used to be a member of a local group called Common Ground, and it brought people together from both sides to have dialogue sessions on abortion-related issues. It was moderated with strict ground rules, so no one could interrupt or become disrespectful. In this fashion, people can talk with one another without coming to blows even when there is heartfelt disagreement. None of us were trying to convert one another, and indeed, conversion wasn’t possible. The pro-life participants were just as vehement about their side as those of us on the pro-choice side were about ours. But we got along and gradually had a better understanding and respect for the other viewpoint. It taught me that one can respect and even admire those with whom there is visceral disagreement.

We need more efforts like that. I remember the 90’s when several abortion providers were murdered along with volunteers and other staff. It seemed to be a reaction to having a pro-choice president in office, in that case, Bill Clinton. The murders can’t be justified, but I would suspect that they were born out of extreme frustration from not having a conservative administration in Washington, DC. Since January 20th, I suppose it was just a matter of time.

So I’m very saddened by the loss of Dr. Tiller. Unlike Warren Hearn, I’ve never personally known or communicated with George Tiller. But his work always meant a lot to me, and women who need a second trimester abortion are worse off due to his loss. However, the cause of reproductive freedom is very much alive, and will continue despite this terrible act of assassination. I hope that my colleagues, regardless of their personal stands on abortion, and medical organizations such as the AMA, come out and strongly condemn this murder. And even better if we can all learn from Dr. Tiller’s example and come together to try to find some common ground on a very divisive issue.

Thanks Chris. I don’t care if someone is pro-life. I do care, however, if someone interferes with patient care when that patient is seeking a legal procedure and also when that person decides to kill someone for delivering abortion services. It’s a sad world.

David, You’re right when you describe the generalities that pro-life people use when discussing the women who seek an abortion. Bring up the issue of rape – especially an underage victim of such a crime who gets pregnant – and you can shut them up pretty quickly.

But I think pro-life people need to realize that an abortion may be done in the interest of the health of the mother. Can you describe such a scenario?

Severe hyperemesis gravidarum (I’ve done at least one for this indication, on the wife of a medical resident who was on hyperalimentation)

Significant mental distress

Of these, cancer, cardiac disease, myasthenia gravis and severe HTN particularly pose risks to the life, not just the health, of the mother. I also think the role of mental distress has been unfortunately misunderstood by the media as well as by many physicians. We’re not talking about having a bad day by continuing a pregnancy. We’re talking about serious mental impairment, which definitely can happen. For example, one of Dr. Tiller’s patients who had an abortion after 20 weeks for an anencephalic pregnancy did not want to sit around for 4-5 more months on a death watch and struggle every day with the doomed pregnancy she was carrying. This was a very desired pregnancy, but it was not viable, and even discounting fetal indications, her mental health was an appropriate reason for terminating the pregnancy. I should add that I had a similar experience with a second-trimester pregnancy that was doomed. My patient felt strongly that her baby was suffering and wanted to terminate. She had a normal pregnancy the year after and got on with her life.

By the way, many pro-life people I have encountered do not consider sexual assault to be an indication for abortion. They believe that the baby shouldn’t have to suffer due to the crimes of the rapist. I disagree. No woman should be an incubator. No victim of sexual assault should ever be forced to bear her rapist’s child.

Not too long ago, a friend of mine in Philadelphia asked for a suggestion for a primary care provider (PCP). I referred him and his wife to our PCP, my wife and I having been that doctor’s patients for 18 years. We rarely see our doctor, truth be told, but he’s a Hopkins graduate, a good internist, and always returns calls personally and promptly.

My friend subsequently e-mailed me to ask for another suggestion, as our PCP has apparently switched to a “boutique” practice and there’s no way they could afford the annual membership fee. Such fees usually range from $1,000 – $3,000 each year. You’d think he was joining a country club or something Our doctor’s switch to a boutique practice was news to me, but as we rarely see our PCP, it’s not surprising we weren’t notified. Our strategy was going to be to hold out and hope our PCP would switch back to a non-exclusive practice, once he realized that this new approach was not popular and he was losing money.

Wishful thinking.

I had to call my PCP today for a referral and as usual, he returned my call personally and within a short period of time. I was asked by his answering service, however, if I was a “VIP” patient. I said we’ve been his patients for 18 years. I mean, that should count for something, right? So I spoke with our doctor about his new boutique practice. He told me that tons of people are signing up, and those who don’t can always see his partner as she still takes insurance. Boutique practices by definition are fee-for-service, cash-only. So in order to continue seeing our PCP of 18 years, we have to pony up a large annual membership fee. Thus, like my friend in Philadelphia, we’re looking for a new PCP.

I can’t blame our soon-to-be former PCP, really. Given that the average physician pays almost $70,000/year to argue with insurance companies it makes little sense any more to participate with third-party payors. This guy is a good doctor and he’s now able to continue doing what he had been doing all along and what he likes to do: practice good medicine in a personalized fashion.

Just like I understand why many of my gynecology colleagues have taken up cosmetic surgery, I understand the allure of boutique medicine. But both of these trends offend my sensabilities and epitomize a medical system gone astray. Boutique medicine establishes another tier in our multitiered health care system. If you have money, youre fine. If not, good luck.

And while I don’t expect all physicians to practice the way I used to practice, I do expect some basic tenets to hold. I returned patient calls. I saw them personally. I didn’t charge extra for what I viewed as quality standard medical practice. Who would have thought I should charge to see a patient in a timely fashion or return their calls myself or write a disability letter? I just stupidly thought this is what one does as a doctor.

So medicine has changed. And not really for the better. If you want to have personalized care like many of us used to provide as a matter of course, you have to pay extra for it. If you’re a surgical gynecologist, you might want to supplement your decreasing revenues from managed care by providing cosmetic services. And so on and so forth.

It’s crazy. Every time I get a hankering to go back to practicing gynecologic surgery, stuff like this gives me the kick in the ass reality check I need to contnue doing the fun stuff I’m doing. But it’s still a shame to see what’s happened to medicine.

The really sad part for patients is that even if you sign up for a boutique service, you *still* have to carry insurance against the possibility of a catastrophic accident. Your fee estimate is a bit low too. We inquired about such a service, but it was $10k per year for a couple.

Part of me roots for the doctor willing to break with the insurance companies to spend more time with his patients and less time filling out paperwork. I bet the care he provides is first-rate. But at the end of the day it is the cost of medical technology that is driving up the price we pay for healthcare. One doctor can’t provide the equipment and facilites routinely required for care today. So we are in the same trap, even if our boutique PCP is an improvement over the 10 minute visit we normally get with the physican working in an industrial-size practice. The scale of medicine has changed, but our public policies have left us behind.

I don’t disagree at all, Paul. It makes perfect sense for the physician. He/She gets to practice the way he/she wants, can limit the number of patients, has a decent income, and doesn’t have to mess with payors. It’s certainly obvious why this would be appealing. But from a larger perspective, this isn’t a good thing for all the reasons I stated.